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Nurse Educator

Vol. 41, No. 2, pp. 93-97

Nurse Educator Copyright * 2016 Wolters Kluwer Health, Inc. All rights reserved.

A Systematic Review of the Literature on Health


Literacy in Nursing Education
Voncella McCleary-Jones, PhD, RN, BC, CNE

Health literacy has an impact on patient health outcomes and should be included in prelicensure nursing curricula to prepare
the next generation of nurses to provide care for patients with limited health literacy. Nursing curricula should go beyond
inclusion of patient teaching strategies. This article provides a systematic review of the current literature related to health
literacy in nursing education and identifies implications for nursing curricula.

Keywords: health literacy; nursing curriculum; nursing education; systematic review

H
ealth literacy has been found to be a stronger predic- patients with conditions such as high blood pressure, diabe-
tor of health status than socioeconomic status, age, tes, asthma, or HIV/AIDS who also have limited health literacy
and ethnic background.1 Health literacy is defined as skills have less knowledge of their illness and its management.5
the degree to which individuals have the capacity to obtain, Low literacy is more prevalent in people with fewer
process, and understand basic information and services needed years of education, those of certain racial or ethnic groups,
to make appropriate decisions regarding their health.2 It is the elderly, and individuals with lower cognitive ability.4 In
estimated that about half of American adults have difficulty addition, individuals with low health literacy are at increased
understanding and using health information, resulting in a risk of health disparities.6 Many health care professionals are
higher rate of hospitalization and use of emergency services unaware which of their patients have limited health literacy
among patients with limited health literacy. 2 Nearly 9 of or how to intervene appropriately.7 Furthermore, patients
10 adults have difficulty using the everyday health informa- with low health literacy may report a sense of shame about
tion that is routinely available in health care facilities, retail their skill level and may hide their reading or vocabulary dif-
outlets, media, and communities.3 ficulties to maintain their sense of dignity.5
Low literacy is associated with difficulty understanding Health literacy should be included in nursing curricula
written or verbal health care advice, adverse health outcomes, to adequately prepare students to provide care in the clinical
and negative effects on the health of individuals.4 An indi- setting.8 Although most curricula include information on the
viduals ability to function in the health care environment patient teaching process, they do not specifically address health
can be affected by low literacy, as well as patient-provider literacy.9 The significant impact of limited health literacy on
communication, and can lead to substandard health care.4 patient outcomes makes health literacy a critical topic area to
Individuals with limited health literacy skills are more likely be addressed in nursing education. This article reports on a
not to seek important preventive measures, such as mammo- systematic review of the current literature related to health
grams, Papanicolaou smears, and flu shots, and enter the literacy in nursing education programs.
health care system when they are sicker, compared with those
with adequate health literacy skills.5 Those with limited health Search of the Literature
literacy are more likely to have chronic conditions and are Methods and Search Parameters
less able to effectively manage them. Studies have found that The aim of the systematic review was to review the litera-
ture that identified health literacy in nursing education.
Author Affiliation: Associate Professor, College of Nursing, University The electronic databases reviewed for the systematic review
of Oklahoma Health Sciences Center. of the literature included CINAHL Complete, MEDLINE
The author declares no conflicts of interest. (OVID), Health Source: Nursing/Academic Edition, Google
Correspondence: Dr McCleary-Jones, College of Nursing, University of
Oklahoma Health Sciences Center, 1100 N Stonewall Ave, Oklahoma City, Scholar, and Digital Dissertations and Theses through Pro-
OK 73117 (voncella-mccleary-jones@ouhsc.edu). Quest. The selected databases included studies found in
Supplemental digital content is available for this article. Direct URL citations nursing journals, state nurses association publications, full-
appear in the printed text and are provided in the HTML and PDF versions text articles, and dissertations. Search parameters included
of this article on the journals Web site (www.nurseeducatoronline.com).
Accepted for publication: June 13, 2015
the years 2000 to 2014, providing a focused search of current
Published ahead of print: July 30, 2015 literature. Search terms included health literacy and nurs-
DOI: 10.1097/NNE.0000000000000204 ing education.

Nurse Educator Volume 41 & Number 2 & March/April 2016 93

Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.


Sources and teaching patients with health literacy issues. The session
CINAHL Complete, MEDLINE (OVID), Google Scholar, and included a case study of a patient with limited health literacy.
Health Source: Nursing/Academic Education produced No data were provided on the number of items on the survey
61 references when the MeSH terms health literacy and instrument or any information about its development.
nursing education were used. The database Dissertation Jukkala et al8 used an instrument with 8 multiple-choice
and Theses through ProQuest produced 26 292 results using questions to examine students and health care providers
these 2 search terms, which required additional search terms knowledge about the impact of limited health literacy on pa-
and limitations to be added to the search criteria. The ProQuest tients and the health system. Content validity was established
database returned 39 results when the following search terms through examination of the instrument by experts in the fields
and limits were applied: and undergraduate, and curricu- of nursing, medicine, and health literacy. Participants were
lum, and nursing PRE/1 education NOT nursing adminis- most knowledgeable about the relationship between level
tration NOT health care. After further review of abstracts, no of education and low health literacy and least knowledge-
dissertations were included from the ProQuest search. One able about the prevalence of limited health literacy in the
pertinent dissertation was included from the Google Scholar United States. While the total sample size was 230, only
search results. 40 participants were students, and 15 participants did not
supply information describing their background. Findings
Analysis and Evaluation should be interpreted in the context of an inability to identify
the total number of nursing students who participated. The
Inclusion and Exclusion Criteria
authors concluded that inability to recognize and intervene
Inclusion criteria for the literature review consisted of studies
for patients with limited health literacy will have an effect on
that examined health literacy, targeted undergraduate nursing
nurses ability to successfully fulfill 1 of their most vital roles
education, and were written in the English language. Exclu-
educating patients on self-care.8
sion criteria included studies focused on health literacy in grad-
Cormier10 used the 44-item Health Literacy Knowledge
uate nursing education and those targeting practicing nurses.
and Experience Survey (HL-KES) to assess the health literacy
Sample Description knowledge and experiences of senior-level baccalaureate
The results of the search yielded 100 references related to nursing students enrolled at state universities in Louisiana.
health literacy and nursing education. Twelve results were Participants identified low socioeconomic groups as high
duplicates and were removed, leaving 88 articles. Based on risk of low health literacy skills and were strongly aware of
the exclusion criteria, 78 references were eliminated. A final the consequences associated with low health literacy skills;
yield of 10 studies was included in this systematic review of however, knowledge gaps existed in identification of the
the literature (see Table, Supplemental Digital Content 1, older adult as a high-risk group, health literacy screening,
http://links.lww.com/NE/A238). Each of the selected studies and guidelines for written health care information.
identified an aspect of health literacy in nursing education. In another study, McCleary-Jones11 used a 5-item tool to
assess students knowledge of health literacy. Students took
a pretest, and posttest after completing an asynchronous on-
Results line educational module. A significant increase in the posttest
The areas of focus in this review of the literature on health mean scores was noted among beginning baccalaureate nurs-
literacy in nursing education included health literacy knowl- ing students. Content validity for the tool was established via
edge, experiences of students in caring for patients with use of a test blueprint to ensure test questions correlated to
limited health literacy, and inclusion of health literacy con- the objectives and content presented, and the Cronbachs !
tent in nursing curricula. These focus areas were further cat- statistic was .173. The finding of increased knowledge among
egorized into 3 themes: learned knowledge and skills, learner students after the educational intervention was similar to the
perceptions, and curricular content. Learners perceptions findings of Sand-Jecklin et al.7
included sensitivity to health literacy, self-confidence in pro- Torres and Nichols12 used the HL-KES to survey associate
moting patients health literacy, respecting different languages, degree nursing students and found participants had some
empathy, and sensitivity to patients life contexts. knowledge about health literacy, but additional instruction
could be beneficial. These findings were similar to those
Learned Knowledge and Skills reported by Cormier.10 The authors recommend introducing
Five studies focused on the health literacy knowledge of health literacy in the first class for incoming students, incor-
nursing students.7,8,10-12 Sample sizes ranged from 53 to porating the Newest Vital Sign health literacy assessment
391 participants, and several different instruments were used tool into clinical assignments, and exposing students to more
to measure health literacy knowledge among the partici- health literacy content throughout the curriculum via a series
pants. Validity data were variable among the instruments used of workshops that address the needs of patients with limited
for data collection. Two of the studies had a pretest-posttest health literacy.
design,7,11 and 3 used a cross-sectional design.8,10,12
Sand-Jecklin et al7 reported a significant increase in stu- Learner Perceptions
dent knowledge about health literacy after a brief 20-minute Four studies focused on the experiences of nursing stu-
educational session for beginning baccalaureate nursing stu- dents in caring for patients with limited health literacy.13-16
dents. Educational content covered the problem of low health Sample sizes ranged from 8 to 146 participants, and different
literacy, identifying it using behavioral cues of patients, Chews qualitative research methods were used to elicit the experi-
3 screening questions, and interventions for interacting with ences of the students; 1 study used a mixed-methods approach.

94 Volume 41 & Number 2 & March/April 2016 Nurse Educator

Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.


Scheckel et al13 elicited the experiences of 8 baccalau- out the nursing program is essential to preparing nursing
reate students in providing patient education via unstruc- students to apply health literacy concepts in their professional
tured interviews, which were analyzed using hermeneutics. practice. Experiencing the struggles of patients with limited
A central theme of addressing health literacy emerged as a health literacy may assist students to understand the impor-
primary practice of students learning and providing patient tance of its assessment in nursing practice.
education. There were 3 subthemes: (a) respecting languages: Zanchetta et al16 used three 1-time individual interviews
learning persistence, recognizing barriers to health literacy and 3 focus groups to analyze students performance and self-
such as using terms like CPR (cardiopulmonary resuscita- assessment of their roles in promoting health literacy. Two
tion), and the meaning of persisting with teaching until the major themes that emerged from thematic analysis were stu-
patient can demonstrate understanding; (b) helping patients dents awareness of challenges to becoming effective health
understand: learning to teach, to facilitate patients under- educators and their sensitivity to health literacy. The researchers
standing of health information via observing nurses teach found that students performed best as health promoters in
effectively with simple instructions and ineffective approaches supportive teaching hospitals. Performance was hindered by
they knew would not result in patients comprehension of clinical settings unsupportive of health education, with an
health information; and (c) promoting engagement: learning absence of role models, and with insufficient theoretical prep-
sensitivity, recognizing that nurses attention or inattention aration for health teaching.
to patients readiness to learn can disengage them from learn- The researchers reported that in multicultural health
ing and understanding health information. These findings care settings students sensitivity to clients diversity reinforced
emphasize the importance of providing health literacy con- the interconnection between health literacy and other social
tent within the nursing curriculum to support the ability of determinants of health. Students recommended that more
nurses to address the education needs of patients with limited socially inclusive and experiential learning initiatives related
health literacy. to health teaching be included to address education gaps
Using qualitative content analysis, Shieh et al14 analyzed between the classroom and practice.16 Each of these studies13-16
narratives written by undergraduate nursing students relat- highlights the importance of inclusion of health literacy con-
ing to experiences in caring for patients with low health lit- tent in the didactic and clinical preparation of nursing students.
eracy. Three themes were uncovered: (a) sensing low health
literacy by behavioral cues, (b) promoting health literacy Curricular Content
with multiple strategies, and (c) closing the health informa- Dunn17 used a cross-sectional design to survey nurse edu-
tion loop. The researchers found students were able to iden- cators in Floridas higher-education institutions regarding
tify behavioral cues suggestive of low health literacy and awareness and application of health literacy in their cur-
provide solutions to increase the patients health literacy. ricula. Eleven of 22 institutions participated in the Florida
However, students did not use standardized tools to assess Nurses Association Health Literacy Committee Survey. The
the patients literacy or knowledge of specific diseases, did author identified a common theme among the responding
not assess readability of patient education materials, and did institutions: health literacy was integrated throughout the
not provide patient empowerment interventions to encour- curricula but was not transparent. For instance, some schools
age active information seeking and participation in self-care. reported health literacy awareness was accomplished through
These findings suggest that even when some health literacy class discussion and stressed with patient education. Another
content is included in curricula, additional information is school stated health literacy was introduced in theory and
needed to adequately prepare nursing students to provide applied in clinical practice, whereas another institution inte-
effective care to patients with low health literacy. grated health literacy through health assessment and health
Weekes and Wyatt15 used a mixed-methods approach promotion for vulnerable groups in their baccalaureate program.
to examine students understanding of limited health literacy
from a patients perspective. Beginning nursing students were Critique of Methods
given a 3-item quiz with questions written using medical Limited health literacy can have significant impact on health
terminology at an advanced level. The students were to use outcomes and is a critical topic area that should be addressed
the information to complete a series of activities including in nursing education. The studies in this review included
identifying nursing priorities for the patient. The students health literacy as a variable for consideration in the knowl-
were then instructed to view a module with information about edge level of nursing students, assessment of learning ex-
health literacy and submit a reflection paper on what they felt periences, and inclusion in nursing curricula. All articles
was the purpose of the quiz, their experience of taking a quiz reported original research, and a variety of instruments and
filled with unfamiliar medical jargon, and how this experience research methods were used to obtain student data. Health
would affect their nursing practice. literacy measurements were clearly reported in all of the ar-
In the postexperience debriefing, most student reflec- ticles, and the research methods appeared to be sound.
tions indicated they understood the purpose of the quiz was It is clear based on the articles included in this review
for them to experience how patients with inadequate and that while health literacy has received much attention in the
marginal health literacy feel. Nearly all of the participants health care arena, inclusion of health literacy content in nurs-
stated they could now empathize with patients who struggle ing curricula has not been widely addressed in the literature.
with health literacy, and the experience would have an im- Initiatives to standardize health literacy content and experi-
pact on their communication with patients throughout their ences in nursing curricula can enhance nursing students ability
nursing career.15 Weekes and Wyatt15 concluded that intro- to provide care to patients who experience limited health liter-
duction of health literacy content early and repeated through- acy and may contribute to improved patient health outcomes.

Nurse Educator Volume 41 & Number 2 & March/April 2016 95

Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.


Implications for Nursing Education health literacy content and experiences. A health literacy
Based on this literature review, areas to be addressed in champion among the nursing faculty can be a positive in-
nursing programs include integrating health literacy content fluence on efforts to include this content and strategies in the
in both didactic and clinical courses and continuing edu- curricula. Currently, health literacy is not included in accred-
cation to update faculty knowledge about health literacy. itation standards; however, it is noted as sample content in
The Table provides specific recommendations for curricular the American Association of Colleges of Nursing Essentials
changes. These strategies will equip students with knowl- of Masters Education in Nursing VIII Clinical Prevention and
edge, skills, and attitudes to interact effectively with patients Population Health, IX Masters-Level Nursing Practice,18 and
experiencing limited health literacy and modify patient teach- also included in Essential IX Baccalaureate Generalist Nurs-
ing strategies and materials for this patient population. ing Practice as a consideration in providing appropriate patient
In the absence of accreditation guidelines for health teaching.19
literacy content and experiences, each faculty will need to
examine its curricula to determine the best placement for
Conclusion
Table. Recommended Health Literacy Content in The available studies revealed that inclusion of health lit-
Nursing Curricula eracy content and experiences in nursing curricula enhances
nursing students awareness, knowledge, and skills regard-
Contenta ing health literacy and provision of care to patients with lim-
Identification of patients with limited health literacy ited health literacy. The systematic review of the literature also
Common signs that indicate low health literacy revealed limited and inconsistent health literacy content in
Tools used to measure health literacy nursing curricula.
Methods to enhance communication with individuals with low literacy Nurses provide teaching and information to patients in a
Methods for verification of patient understanding of health care variety of health care settings. It is important that nursing
information taught curricula include information on health literacy to enhance
Evaluation of patient teaching materials for health literacy level the awareness of future nurses of the impact that limited
Best practices for simplifying written material health literacy can have on patient outcomes, and strategies
Use of pictures in patient education that can be implemented in providing care to patients with
Adverse medication events and limited health literacy limited health literacy.
Plain Language resources
Ask Me 3 communication
Psychosocial issues for patients with limited health literacy References
Impact of limited health literacy on patient outcomes, health system, and costs 1. Nath C. Literacy and diabetes self-management. Am J Nurs. 2007;
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Teaching Strategies 2. Nielsen-Bohlman L, Panzer A, Kindig D. Health Literacy: A
Prescription to End Confusion. Washington, DC: Institute of
Watch videos depicting the impact of limited health literacy on patient Medicine, National Academies Press; 2004.
health outcomes and on patient interactions with health care providers 3. Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of
Universal precautions strategy: approach all patients with assumption Americas Adults: Results From the 2003 National Assessment
they are at risk of not understanding their health conditions or how to of Adult Literacy (NCES 2006-483). Washington, DC: US Depart-
deal with them, then confirm and ensure patients understanding ment of Education, National Center for Education Statistics; 2006.
(http://www.nchealthliteracy.org/toolkit/introduction.pdf) 4. US Department of Health and Human Services. Agency for Health
Complete evaluations of patient education materials for health literacy care Research and Quality. Literacy and health outcomes: summary.
level prior to use in patient teaching 2004. Available at http://www.ahrq.gov/clinic/epcsums/litsum
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Practice completing health literacy assessments on volunteers, eg, students, Prevention and Health Promotion. Quick guide to health literacy
family members, friends fact sheet. Health literacy and health outcomes. Available at
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factsliteracy.htm. Accessed May 24, 2015.
Role play teaching patients with limited health literacy and teach-back
6. Sentell TL, Halpin HA. Importance of adult literacy in under-
techniques in various case presentations, such as acute care, mental
standing health disparities. J Gen Intern Med. 2007;21(8):862-866.
health, gerontology, pediatrics, others
7. Sand-Jecklin K, Murray B, Summers B, Watson J. Educating
Develop teaching plans appropriate for patients with limited health literacy nursing students about health literacy: from the classroom to the
Conduct a brown bag assessment of prescribed medications with all patient bedside. Online J Issues Nurs. 2010;15(3):1.
assigned patients 8. Jukkala A, Deupree J, Graham S. Knowledge of limited health
Identify local literacy resources in the community, such as adult literacy at an academic health center. J Contin Educ Nurs. 2009;
education programs and literacy leagues 40(7):298-302.
Practice revising health care materials using Plain Language guidelines 9. Cornett S. Assessing and addressing health literacy. Online J
(http://www.plainlanguage.gov/resources/index.cfm) Issues Nurs. 2009;14(3):1.
Conduct simulations and debriefings for scenarios related to health 10. Cormier C. Health Literacy: The Knowledge and Experiences
literacy, eg, patient education, communication, patient safety of Senior Level Baccalaureate Nursing Students [dissertation].
New Orleans, LA: Louisiana State University; 2006.
a
Integrate health literacy content throughout curriculum 11. McCleary-Jones V. Assessing nursing students knowledge of
health literacy. Nurse Educ. 2012;37(5):214-217.

96 Volume 41 & Number 2 & March/April 2016 Nurse Educator

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12. Torres R, Nichols J. Health literacy knowledge and experiences 16. Zanchetta M, Taher Y, Fredericks S, Waddell J, Fine C, Sales R.
of associate degree nursing students: a pedagogical study. Teach Undergraduate nursing students integrating health literacy in
Learn Nurs. 2014;9(2):84-92. clinical settings. Nurse Educ Today. 2013;33(9):1026-1033.
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Teaching Psychomotor Skills in Nursing


Are students in your nursing program competent in performing psychomotor skills? It may be that we are not providing
sufficient practice for students to develop their competency. In learning a motor skill, students first need to understand the skill
and how to perform it accurately. To gain proficiency, they have to practice it and receive feedback to correct any errors.
With practice, students learn to do it more quickly. Movements become more consistent.1 Further practice enables them to
perform the skill without thinking through each step. If students do not use or practice a skill after their initial instruction in the
laboratory, it is unlikely they will retain it particularly as time goes on. We need to integrate practice of essential psychomotor
skills in simulations, clinical practice, and laboratory experiences throughout the curriculum. This will help students retain their
skills and become more competent in performing them. Consider using dyad practice in which students alternate between
observing and physically practicing the skill. When students observe their partner performing the skill, they gain insight into
aspects of the skill that are difficult to notice when doing it themselves.2 Dyad practice can improve performance and retention,
and it is efficient (2 students at a time).

Submitted by: Marilyn H. Oermann, PhD, RN, ANEF, FAAN, Editor-in-Chief, marilyn.oermann@duke.edu.

References
1. Schmidt RA, Lee TD. Motor Control and Learning: A Behavioral Emphasis. 4th ed. Champaign, IL: Human Kinetics; 2005.
2. Granados C, Wulf G. Enhancing motor learning through dyad practice: contributions of observation and dialogue. Res
Q Exerc Sport. 2007;78(3):197-203.

DOI: 10.1097/NNE.0000000000000245

Nurse Educator Volume 41 & Number 2 & March/April 2016 97

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